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Cambridge University Press
Online publication date:
December 2010
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Book description

The paroxysmal disorders present neurologists and other medical professionals with diagnostic problems across a range of disorders, including multiple sclerosis, migraine and epilepsy. This new English language edition of a compendium of the paroxysmal disorders, originally published in German as Paroxysmale Störugen in der Neurologie, is an informative and practical resource for clinicians, which provides invaluable help with differential diagnosis and management. Fully updated throughout, this new edition comprehensively covers the entire spectrum of the paroxysmal disorders, including sudden falls, headache, vertigo attacks, memory loss, visual disturbances, seizures and anxiety. Each chapter is practice oriented, covering definitions, etiology, epidemiology, diagnosis, examination techniques and therapy. Detailed guidelines for gathering case-histories, essential for accurate diagnosis, are also provided. Important reading for clinicians, professionals and academic researchers working in neurology, psychiatry, epilepsy, internal medicine and ENT.

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  • Chapter 8 - Paroxysmal paresis
    pp 89-112
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    The gold standard case history is of particularly high importance in paroxysmal disorders because many seizures may comprise a variety of subjective symptoms or may even consist exclusively of these symptoms. Taking a seizure history is primarily for diagnostic purposes, largely to differentiate epilepsy from other seizure-like disorders but also to distinguish between different types of epileptic seizures and to understand the anatomy and etiology of these events. Hypotheses are formed, followed-up or refuted, and they determine the subsequent course of the interview. Such an in-depth dialogue also opens up perspectives beyond diagnostics. Beyond providing diagnostic clues and anatomical understanding, another frequent consequence of these interviews is indications for the best further therapeutic strategy. Verbal communication is only successful when the partners in dialogue find a common language. A dialogue is frequently necessary to get the full picture of all subjective seizure symptoms and their sequence.
  • Chapter 9 - Paroxysmal dyskinesias
    pp 113-129
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    An epileptic seizure is diagnosed according to clinical findings, including a thorough history and neurological examination with corresponding diagnostic studies, for example, electroencephalography (EEG). Jactatio capitis/corporis nocturna is characterized by rhythmic stereotype head-rolling or body-rocking movements while falling asleep during sleep stage I, or during short arousals during sleep stage II. Syncope is a brief, temporary loss of consciousness due to a transient reduction of cerebral perfusion. Prodromes such as lightheadedness or ringing in the ears in situations involving, for example, long periods of standing upright in poorly ventilated rooms are immediately suggestive of syncope. Narcolepsy is a disorder rarely seen in infants; however, single cases have been reported in patients under four years of age. As with paroxysmal torticollis, a connection between benign paroxysmal dizziness and migraine is also suspected. Symptoms can be suppressed by low-level doses of antiepileptic medication such as phenytoin, carbamazepine/oxcarbazepine or valproic acid.
  • Chapter 10 - Cramps, spasms, startles and related symptoms
    pp 130-144
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    This chapter describes the clinical characteristics of syncope and its distinction from generalized tonic-clonic seizures, which cause the most difficulties in daily clinical practice. The high variability of frequencies at which convulsions in syncope were observed is explained by their highly variable presentation. The most important criterion to differentiate syncopal and epileptic convulsions is their specific phenomenology. Presyncope is the prodromal stage of syncope in which there is only a less pronounced hypoperfusion of the brain and therefore no complete loss of consciousness. Syncope can also appear after eating a carbohydrate-rich meal, particularly in elderly patients. Syncope associated with migraine is particularly frequent in basilar migraine. This form of migraine occurs mostly in adolescent girls and young women. The initial evaluation of a patient presenting after loss of consciousness includes a thorough history, a physical examination, supine and upright measurement of blood pressure and pulse rate, and an electrocardiogram (ECG).
  • Chapter 11 - Myoclonus
    pp 145-157
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    The control of posture, stance and motion is highly demanding of the peripheral and central nervous system of a creature, especially if this creature is a relatively fast-moving bipedal one with a high center of gravity. With a sustained cerebral hypoxia/anoxia, a tonic phase with or without myoclonia, that is convulsive syncope, appears. Drop attacks of the vertebro-basal circulation are caused by a transient ischemia of the cortical spinal pathways or the paramedian reticular formation. Cataplexia is defined by a paresis of the skeletal muscles due to a sudden emotion. The triggering emotions are usually of a positive nature. Cataplectic attacks are most commonly triggered by sudden laughter. In startle diseases, the physiological startle reaction is pathologically increased and leads, among others things, to a paroxysmal loss of control of the body posture. In typical absence seizures, the semiology and EEG findings strongly indicate the diagnosis of idiopathic epilepsy.
  • Chapter 12 - Paroxysmal memory loss
    pp 158-163
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    According to the criteria of the International Headache Society (IHS), a migraine is defined as a disease with periodic occurring headache episodes, typically associated with autonomic symptoms. The release of neuropeptides explains the actual origin of pain but not how and why the attack begins so abruptly in humans. Triptans improves the typical additional symptoms like nausea or vomiting, photo- and photophobia, and improves the ability to return to work. During a migraine attack, most patients suffer from gastrointestinal symptoms. The aim of migraine prophylaxis is a reduction of frequency, severity and duration of migraine attacks and the prevention of medication overuse headache. Effective for preventive migraine therapy are the non-selective beta-blocker propranolol and the beta-1-selective beta-blocker metoprolol. Most psychological treatments used in migraine therapy are behavior therapies. Paroxysmal pain of short duration located in a region of one of the trigeminus nerves is very characteristic for the trigeminal neuralgia.
  • Chapter 13 - Dissociative seizures
    pp 164-179
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    This chapter focuses on the most frequent vertigo syndromes. Characteristic symptoms of Benign paroxysmal positioning vertigo (BPPV) include brief, in part, severe attacks of rotatory vertigo with and without nausea, which are caused by rapid changes in head If the typical positioning nystagmus can be elicited without any additional central signs and symptoms. Menière's disease is typically a combination of abruptly occurring attacks with vestibular and/or cochlear symptoms, fluctuating, slowly progressive hearing loss and, in the course of time, tinnitus. Vertigo and nausea are reduced by antivertiginous drugs used in other acute disorders of labyrinthine function, for example, dimenhydrinate 100 mg as suppository or benzodiazepine. The differential diagnosis of perilymph fistulas includes the following illnesses: BPPV, positional vertigo of central origin, Menière's disease, vestibular paroxysmia, somatoform phobic postural vertigo, labyrinthine trauma and bilateral vestibulopathy. Differentiating vestibular migraine from transient ischemic attacks, Menière's disease or vestibular paroxysmia can occasionally be difficult.
  • Chapter 14 - Anxiety
    pp 180-187
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    Phenomenological differentiation of delusions into illusions and hallucinations is generally useful. Different forms of visual delusions have typical clinical characteristics, which presumably account for different pathophysiological correlates. All forms of visual perseveration occur paroxysmally, if they are the result of a brain lesion, and are usually unilateral and then contralateral to the lesion. Various casuistic data reveals how different the pathogenesis of visual palinopsia can be: epilepsy, intracranial tumor, cerebral infarction, migraine, traumatic brain injury and so on. Polyopia presents special type of visual perseveration. Photopsias, also called phosphenes or photomes, appear in different diseases. Before a neurological disorder is taken into consideration, diseases of the eye or intoxication and side effects of medicine should be excluded. The pathogenesis of the hallucinations is diverse; the visual hallucinations in epilepsy are most frequently the result of traumatic brain injury, cerebral hemorrhage or, occasionally, cerebral ischemia or tumor.
  • Chapter 15 - Vegetative seizures
    pp 188-195
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    The most common cause of paroxysmal paresis of one side of the body with or without other associated symptoms is transient cerebral ischemia. The majority of patients with a paroxysmal paresis need a cerebral imaging. In the initial phase of encephalitis, transient focal neurological symptoms occur including paresis which poses like transient ischemic attacks (TIA). Acute paraparesis or paraplegia consists in most cases in incomplete or complete paresis of the legs. The rare paresis of both arms is called diplegia brachialis. In patients with acute teraparesis or tetraplegia, the first differential diagnosis is a spinal lesion in the upper part of the cervical spine. Associated are commonly sensory symptoms and bladder or bowel function disturbance. In cases of an acute paresis of one extremity or even only singular muscle groups of one extremity, a monoparesis or monoplegia is present depending on the fact if the paresis is incomplete or complete.
  • Chapter 16 - Episodic ataxias
    pp 196-208
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    Paroxysmal dyskinesias are a heterogeneous group of disorders characterized by intermittent attacks of hyperkinetic involuntary movements without loss of consciousness. The paroxysmal movements may affect the arm or leg on one or both sides of the body, or all extremities. All kinds of paroxysmal dyskinesias may be symptomatic in origin. Twenty-two percent of one series of patients with paroxysmal movement disorders had underlying causative diseases. History and neurologic examination are the cornerstones on the way to the diagnosis of paroxysmal dyskinesias. The paroxysmal nature and predominantly short duration of the attacks, the aura symptoms and the response to even low doses of anticonvulsant drugs suggest that paroxysmal dyskinesias closely resemble epilepsy. Sandifer syndrome is a rare movement disorder in toddlers. During or immediately after feeding, affected children exhibit severe dystonic movements or postures of the head and neck. They often vomit and are malnourished.


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